1. National Association of County & City Health Officials
MAPP & Unnatural Causes: A Strategic Approach to Tackling Health Inequities
Julia Joh Elligers, MPH
National Association of County & City Health Officials
APHA Annual Meeting
Wednesday, November 10, 2010

2. Agenda Understanding terms and concepts
Doing public health work with an equity lens
Using MAPP as a tool to address health inequity
MAPP & Unnatural Causes in Memphis-Shelby County
Resources
First, I will provide an overview of Health Equity as NACCHO understands it. Then, we will turn to a discussion of how to approach your daily public health practice through a public health lens. Finally, I will highlight a few resources NACCHO has available to help you begin thinking about health equity.
Before we begin, however, I’d like to mention a few things. First, my background is not in public health– I came from a progressive, political communications background. Health equity work does not have to be explicitly political but the topics it addresses and the forces in society it seeks to correct often require deep, informed dialogue.
Also,
The information provided in this session about SJ is based on information I gather from experts in the area, including the contributors to the recent publication Tackling Health Inequities Through Public Health Practice: theory to action that you all read a few chapters from before today’s meeting.
In addition, please keep in mind that how to address health inequities remains a topic in which folks disagree. I will speak about NACCHO’s positions today that evolved over the course of the past years.
What I will be sharing is some basic information that has helped other folks begin to make a paradigm shift in the way they think about public health.

3. Terminology Health Disparities Health Inequities
Difference in the distribution of disease and illness across populations.
Health Inequities
Systemic, unfair , avoidable, and unjust differences in health status
and mortality rates. (adapted from M. Whitehead)
Social Determinants of Health Inequity
Economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole.
Social Justice
Social justice includes economic and social justice, political justice and participation, emancipation and liberation, and autonomy.
NACCHO uses the term health inequities because the differences between population groups are the result of unjust practices. We do not want to suggest that these differences are somehow “natural.” It also implies our moral obligation to act. Disparities shows a difference… not what is behind, the cause of the difference.
Equity: social standings, ways law is structured, policies, procedures like cultural exclusion, can’t have equity without equality.
Equality: legalistic, e.g. equal access to services, doesn’t acknowledge systems in place that puts different groups at a disadvantage
The root causes of health inequities are deep social divisions and opression. However, no 1:1 ratio exits between core social injustices and the form that will elimate the health inequity– lots of work is needed in a variety of fields. Public health, however, is in a unique position to “bring everyone to the table.”
Social determinants is the manifestation of health inequity… not the root of the problem.
In order to address health inequity, need to adopt a social justice framework. Social justice framework helps identify the reasons behind social determinants.
Social Justice offers a larger framework that motivates our work towards health equity. Achieving health equity is simply one step towards creating a just society.
There are certain principles of SJ that have to do with economic and social equality and other hand political equality/democracy.
Two other features of SJ… emancipation/liberation from oppression
Example of autonomy.. Control over your life.
Not just about distributional justice… not about making people the same or have the same amount of income.
There are different types of injustice not related to distribution. A whole variety of oppression… social exclusion
SJ is a rich concept… not just about fairness.
Not excluded from historical context.
The difference between fixing something and changing the structure. Repair versus stopping the source of injustice.

4. Using a Social Justice Framework to Address Health Inequities
How social, political, economic institutions are organized Social, economic, political inequality  Unequal structuring of life changes  Health inequities Central social justice question: “Why is there inequality and how can our organizational structure, policies, and practices change to eliminate health inequities?” (Hofrichter)
First, I will provide an overview of Health Equity as NACCHO understands it. Then, we will turn to a discussion of how to approach your daily public health practice through a public health lens. Finally, I will highlight a few resources NACCHO has available to help you begin thinking about health equity.
Before we begin, however, I’d like to mention a few things. First, my background is not in public health– I came from a progressive, political communications background. Health equity work does not have to be explicitly political but the topics it addresses and the forces in society it seeks to correct often require deep, informed dialogue.
Also,
The information provided in this session about SJ is based on information I gather from experts in the area, including the contributors to the recent publication Tackling Health Inequities Through Public Health Practice: theory to action that you all read a few chapters from before today’s meeting.
In addition, please keep in mind that how to address health inequities remains a topic in which folks disagree. I will speak about NACCHO’s positions today that evolved over the course of the past years.
What I will be sharing is some basic information that has helped other folks begin to make a paradigm shift in the way they think about public health.

5. Applying an equity lens to public health work
Traditional v. Social Justice
Personal responsibility and individual behaviors
Causes of inequity: genes, bad behavior, accident
Resolution: behavior change; treatment of symptoms
General approach: acceptance of risk as fact of life
Social responsibility to protect common good
Causes of inequity: racism, class and gender exploitation
Resolution: tackling racism, class and gender exploitation through political action
General approach: activist perspective to creating conditions for good health
Here is a comparison between what I term the “traditional” approach and what scholars on the subject call “Market Justice vs. Social Justice”. Essentially, traditional public health work looks at how to treat the symptoms– home visits, clinics, etc. While Social justice works on the reason these symptoms manifest themselves in particular communities.
Rather than looking at individual behavior and personal responsibility, the social justice approach contends that there are broader social forces - that derive from injustices, associated with social economic and political inequality - that impact individual behavior. Thus racism, class and gender exploitation help to explain why groups of people have a higher rate of illness or show more prevalence to risky behavior.
We should note that public health started out as a population based approach and overtime has evolved into the market-Justice approach we are more familiar with today. In the 19th century, during the industrial revolution, a services of social movements and legislation with clear effects on health included the limit to the length of the working day, child labor laws, and the sanitary reform movement.
Obesity
Traditional: people don’t eat well, don’t take care of themselves; if we educate them, they could change their behavior
SJ: are their sources of healthy food, why isn’t there access to healthy food, is it a zoning issue, who influences that policy

6. Changing the Questions
Instead of only asking:
Perhaps we should also ask:
Who lacks health care coverage and why?
What policy changes would redistribute health care resources more equitably in our community?
How can we create more green space, bike paths, and farmer’s markets in vulnerable neighborhoods?
What policies and practices by government and commerce discourage access to transportation, recreational resources, and nutritious food in neighborhoods where health is poorest?
Why do people smoke (drink)?
What social conditions and economic policies predispose people to the stress that encourages smoking (drinking)?
Example here from BPHC re: asthma rates, home visits, and pesticide usage and new PH questions. Much of this is about taking a step back and asking a secondary question. So it isn’t just “How can we relieve the suffering in community X but WHY is community X suffering in the first place
In order to begin to address health inequity, we need to change the questions we are asking. Access to care and community design related issues often come up in MAPP communities. So I wanted to use these areas as an example. So: Rather than ask
Why do people lack health care coverage?
We need to ask
What policy changes would redistribute health care resources more equitably in our community?
For walkability, we should be looking at
The policies and practices by government and commerce that discourage access to transportation, recreational resources, and nutritious food in neighborhoods where health is poorest.
And back to our smoking example:
Why do people smoke? Looks at the behavior of smoking.
What social conditions and economic policies predispose people to the stress that encourages smoking (drinking)? Looks at what forces are causing people to take up smoking that are outside of their control.
These bigger picture, population based questions have the potential to have a great impact. Rather than influencing the behaviors of millions of smokers one at a time, by influencing policy and social conditions, we can address factors that impact populations all at once. ?”

7. Transforming Public Health Practice
Workforce Development and Staff Education
Working Effectively with Communities
Communications: Framing Strategy for Staff, Public, and Mass Media
Building Strategic Alliances
Advocacy
Monitoring and Surveillance
Public Policy Development and Analysis
Integration of Disciplines and Agency Work
Redeploying Organizational Resources
these are the suggested elements of how to transform public health practice to be able to address health inequities. MAPP falls in line with a number of these elements. (next slide)
There are a lot of ways a social justice approach can be folded into existing work.
Consciously thinking about health inequity—not disparities—when doing these work
Dimensions of public health practice… what they do as part of everyday practice.

8. MAPP & Health Equity Workforce Development and Staff Education
Working Effectively with Communities
Communications: Framing Strategy for Staff, Public, and Mass Media
Building Strategic Alliances
Advocacy
Monitoring and Surveillance
Public Policy Development and Analysis
Integration of Disciplines and Agency Work
Redeploying Organizational Resources
MAPP has elements that will help support addressing health inequities through a social justice approach, mainly that it is based on true partnerships with the community, inclusion being the foundation of any health equity solution. Collaborating with Communities
Building Strategic Alliances – because MAPP is based on a strong partnership with groups other than traditional health partners but uses a broad definition of public health when identifying partners, and these partnerships are not uni-directional, MAPP can help the LHD develop strategic alliances. Alliances with people with power.
Advocacy – because the community is involved in MAPP, they become more aware of the issues discussed and raised, which create more informed and more powerful advocates for public health issues (including social determinants) affecting the community.
Public Policy Development and Analysis – with advocates from the community, organizations, and government agencies, public policy in the interest of the public health issues facing that community can be developed, including social determinants of health. Institutional procedures. Most social policies have health implications
Integration of Disciplines and Agency Work – Typically public health is planned through a siloed approach. We get money for immunization or MCH and we develop plans around how we are funded. MAPP, however, takes a bigger picture, cross-cutting approach to planning, which is why we consider it strategic planning. It looks at the overlaps and functions not only within the LHD, but within the entire system. As such, when we talk about MAPP being a new way of doing business, to a certain extent we are talking about the integration of disciplines and how the system functions.
Redeploying Organizational Resources – MAPP requires that systems reorganize resources in a more coordinated approach and towards strategic issues.

9. Mobilizing for Action through Planning & Partnerships
A community-wide strategic planning process for improving public health.
A method to help communities prioritize public health issues, identify resources for addressing them, and take action.
More formally, MAPP stands for Mobilizing for Action through Planning and Partnerships.
MAPP is a community-wide strategic planning process for improving public health, as well as an action oriented process to help communities prioritize public health issues, identify resources for addressing them, and take action.

10. Three Keys to MAPP Strategic Thinking Community Driven Process
Focus on the Local Public Health System
State: There are three keys to MAPP.
The first key is strategic thinking. MAPP is unique because it is based on strategic planning concepts, and - in order to be successful - requires creative, long-term strategic thinking.
The second key to MAPP is that MAPP is a community driven process. MAPP relies on participation from a wide range of individuals, groups, and constituencies in the community. Since the community drives the process, the process has credibility, ensures ownership and creates sustainability over time. It can also create greater advocacy for public health.
The third key to making MAPP successful is the use of a broad definition of the Local Public Health System. This recognizes that public health is provided by more than just the local health department. Other organizations such as hospitals, businesses, faith organizations, and community-based organizations play a critical role in assuring the public’s health. The local public health system includes all public, private and voluntary entities, as well as individuals and informal associations that contribute to public health services.
Its these latter two concepts of MAPP that are the most valuable as a means to begin addressing Health Inequities. Using a bottom up process, rather that an agency driven process enables agencies to gain a better understanding of the real obstacles communities face, as well as the resources those communities have.

11. Local Public Health System
Transit
Civic Groups
Employers
Patient Advocacy
Mental Health
Faith Instit.
Law Enforcement
Labor Unions
Elected Officials
Social Worker
Parks and Rec
Public Health Dept
Dentists
Drug Treatment
Tribal Health
NGOs
When I talk about the LPHS, it is all the entities that, collectively, address local public health…these include government, private, and non-profit organizations and agencies. It also includes the state and CDC. Again, we’re thinking in terms of a broad definition of health.
A Public Health System is complex. Here is a depiction of the complexity of a public health system and examples of organizations and groups that comprise the network. You can see many of the system partners represented who contribute to health and delivery of the Essential Public Health Services.
*MAPP talks a lot about community ownership and community engagement. This refers both to the agencies represented in this depiction of the local public health system, but it also refers to the broader community – to community residents.
Fire
Labs
Home Health
CHCs
Corrections
Neighborhood
Orgs.
Civil Rights Organization
Schools
City Planners

12. MAPP Model
There are six phases in the MAPP process. This model shows the six phases in a linear fashion down the middle of the graphic. The four arrows surround the linear process to illustrate that the information and outcomes from the four MAPP assessments are crucial to driving the entire MAPP process.
Organize for Success and Partnership Development phase allows you to plan a MAPP process that builds commitment, engages participants, uses their time well, and results in a plan that can be implemented successfully.
The visioning process is a collaborative and creative approach that leads to a shared community vision and common values.
There are Four MAPP Assessments - Community Themes and Strengths, Local Public Health System, Community Health Status, and Forces of Change.

13. MAPP Framework
Health Equity Actions
All phases
Engage with communities to develop their capacity and resources to participate fully in social and political processes
Phase 3: Four MAPP Assessments
Mandate a reexamination of public health priorities, practices, and use of resources
Phase 3: Forces of Change Assessment
Communicate facts about the forces that produce or undermine health to their constituencies, responsible public institutions, and political leaders
Phase 4-6: Identifying Strategic Issues, Formulating Goals & Strategies, Action Cycle
Develop a policy agenda for health equity and identify strategic activities with constituencies that supports this agenda

14. More examples of health equity action
Establish a health equity team of core, diverse, cross-disciplinary members that would lead the effort to identify the root causes of health inequity.
Assess staff understanding of health equity Develop interagency/multidisciplinary coordination
Identify how the workforce can more systematically respond to the root causes of health inequity
Raise awareness and encourage dialogue about health inequities
Analyze and develop policies in an effort to address the sources of health inequity.
these are the suggested elements of how to transform public health practice to be able to address health inequities. MAPP falls in line with a number of these elements. (next slide)
There are a lot of ways a social justice approach can be folded into existing work.
Consciously thinking about health inequity—not disparities—when doing these work
Dimensions of public health practice… what they do as part of everyday practice.

15. Adapting MAPP
Build strategic alliances with partners in SJ community to determine the right questions.
Conduct assessments that ask the right questions.
Look beyond behavior at the root cause of each strategic Issue when developing goals and strategies.
Include strategic partners in every phase.
Consequently, in order for MAPP to be an effect tool for addressing health inequities, communities must make modifications to the tool.  Fortunately, one of the strengths of the tool is it's flexibility. 
Be consciously aware that you are interested in looking at root causes when you are inviting partners to the table. 
The groups/organizations/people represented in your MAPP process will dictate the extent to which you will be able to address health equity issues effectively. 
Second, modify the questions asked during the assessments to get at systemic, social inequalities that will lead to differential health outcomes. 
Specifically, you could supplement the Community Health Status Assessment with the Social Determinants of Health Equity Index currently being developed by The Connecticut Association of Directors of Health.
It is described in the Tackling Health Inequity book.
And once strategic issues are developed, look beyond behavioral factors towards root causes when you are developing goals and strategies.
In addition, the MAPP process does not fall on one agency, and doesn’t look to the LHD to implement the activities alone.
Consequently, MAPP communities can more readily look to their community partners who may be in a better position to work on root cause areas.
The benefit is that those partners are now armed with health data to support their cause, and the cause of public health.
In every decision we make in Public health there is an underlying value we are using in how we determine the merit of one course of action versus another.
Inequality is as valid a reason for health outcomes as behavior.
Central Social Justice Question: “Why is there inequality and how can our organizational structure, policies, and practices change to eliminate health inequities?”

16. Learn More NACCHO’s Health Equity Toolkit
Learning Collaborative for Health Equity and Social Justice
Funded by the NIH
Will be launched in July 2011
Tackling Health Inequities through Public Health Practice: Theory to Action
edited by NACCHO staff member Richard Hofrichter and NACCHO member Rajiv Bhatia.
Use the promotional flyer for 20% off the list price.

17. First Steps
Local Health Department National Coalition for Health Equity
Build solidarity and share experiences
Develop public policy agendas
Identify the need for training
Increase public awareness.
Unnatural Causes are free for LHDs
Tools in NACCHO toolkit to support communities hosting public screenings
NACCHO’s Health Equity Campaign
Receive a free copy of Unnatural Causes if your department agrees to host a public screening and dialogue session.

18. Health Equity Staff Contacts
Richard Hofrichter, PhD Senior Analyst, Health Equity & Social Justice (202) direct Ashley Bowen, MA Program Associate, Health Equity & Social Justice (202) direct

19. MAPP Staff Contacts
Julia Joh Elligers, MPH Program Manager, Assessment & Planning (202) direct Mary Kate Allee, MPH Senior Analyst, Assessment & Planning (202) direct

20. Achieving Health Equity is Everybody’s Business
Cynthia D. Nunnally, MPH. CHES
Shelby County Health Department
Memphis, TN
American Public Health Association Annual Meeting
November 10, 2010, Denver, Colorado

21. MAPP Staff Contacts Julia Joh Elligers, MPH
Program Manager, Assessment & Planning
(202) direct
Mary Kate Allee, MPH
Senior Analyst, Assessment & Planning
(202) direct

22. A HEALTHY SHELBY COUNTY…
M.A.P.P. Visioning
A HEALTHY SHELBY COUNTY…
Good place to raise children
Good jobs/healthy economy
Good schools

23. M.A.P.P. Priorities Heart Disease, Stroke and Diabetes
Infant Mortality
HIV/AIDS
Violence
Teen Pregnancy

24. UNNATURAL CAUSES Is inequality making us sick?
Do we all have an EQUAL chance for health?
UNNATURAL CAUSES

25. Public Health Partnership
Shelby County Health Department
University of Memphis

26. Our Plan Community Dialogue Neighborhood Identification of Priorities
Community Capacity Building and Leadership Development
Asset-based Community Development and Asset Mapping
Health and Wellness Prevention Education
Coaching and Consultation
Priority setting
Action planning
Implementation
Resource identification
Advocacy

27. CASTING THE NET

28. Inviting Everyone to the Table
Health Department Workforce
Community Resources – Government
Community Resources – Non-Government

29. Inviting Everyone to the Table
Neighborhood Associations
Boards of Directors of Non-profit Organizations
Health Department Coalitions
General public

30. Organization Interviews
Obtain information on the goals and objectives of participant organizations
Obtain information on the current resources and limitations of participant organizations
Identify the gaps or duplication of resources available to communities from RHC members
Discern the importance of community engagement to participant organizations

31. Key Informant Interviews
What is your community history?
What changes have you seen in your community over the past 5, 7, or 10 years regarding employment, health, crime, socioeconomic status, attitudes, and demographics?
What community organizations are you involved with in your community?
What strengths are present in your community to build upon in making positive improvements in your community?

32. Key Informant Interviews
Are there any health-related projects being implemented that you are involved in?
What do you think are the main concerns/issues of your community and rank with the most important being number 1?
Do you believe there are factors in your community that are keeping it from doing what needs to be done to improve the health and quality of life?

33. O.R.I.D. Method Objective: What does the data say?
Reflective: How do you feel about the data?
Interpretative: What are the implications?
Decisional: What are we going to do about it?

34. Call to Action Gardenview Neighborhood Association (Southeast Memphis)
University Neighborhood District Corporation
(East Memphis)
A Better Memphis (North Memphis)
St. Andrew A.M.E. Church (South Memphis)

35. What’s ahead…
“I AM BECAUSE WE ARE.” Asante Proverb